Abstract

Background: In this study, we aimed to investigate the effect of
central venous catheterization under ultrasound guidance on the
success and complication rates in low-weight infants (under 5 kg)
undergoing surgery due to congenital heart disease.

Methods: A total of 70 infants (38 boys, 32 girls; mean age of
patients <1 month was 16.4±9.5 days [n=20; 28.6%]; 1-7.5 months
was 126.3±47.8 [n=50; 71.4%]) who underwent ultrasound-guided
internal jugular venous catheterization between October 2014 and
October 2015 were retrospectively analyzed. All catheterizations
were done under the guidance of ultrasound by two skilled
anesthesiologists. Data including demographic characteristics of
the patients, procedural success rate, catheter access time, number
of attempts, and complications were recorded.

Results: The overall success rate of the procedure was 92.8%
(n=65). In 82% of the patients (n=53), the insertion was successful
at the first attempt. The mean catheter access time (time from
the first puncture to the catheter insertion) was 214±0.48 sec.
Complications were seen in five patients (7.14%), and the body
weight of these patients was less than 2,500 g. There was no
arterial puncture in any patients. One patient (1.42%) developed
pneumothorax and four patients (5.7%) developed hematoma due
to repeated attempts.

Introduction

Central venous catheterization (CVC) in pediatric
patients with congenital heart disease weighing less
than 5 kg is often difficult and may be associated with
a high risk of complications, even with ultrasound
(US) guidance. Low body weight may reduce the
success rate, while increasing the complication rate
and number of insertion attempts of central venous
cannulation. In particular, US is recommended in
low-body-weight pediatric patients and has been
shown to be superior to conventional landmark
technique.[1-5]

In recent years, the use of US as a guide has
been increasing to reduce the risks associated with
central venous catheter insertion. Several publications
have demonstrated its role as a complementary tool
in pediatric patients by reducing the incidence of
complications during the catheter insertion.[5,6] With
the guidance of US, it is also possible to identify
the size and location of the vessel and to evaluate
the presence of congenital anomalies and anatomic
variations.[1,4]

Various factors contribute to the success rate of
CVC, including patient characteristics, comorbidities,
and access site. The most common complications
include bleeding, hematoma, arterial puncture, and
pneumothorax.[5]

In the present study, we aimed to evaluate the
efficacy and safety of US-guided internal jugular vein
(IJV) cannulation in terms of the complication and
success rates in pediatric patients with congenital heart
disease.

Methods

In this study, medical records of a total
of 70 low-weight infants weighing less than 5 kg
(38 boys, 32 girls; mean age of patients <1 month
was 16.4±9.5 days [n=20; 28.6%]; 1-7.5 months was
126.3±47.8 days [n=50; 71.4%]) who underwent
US-guided IJV catheterization due to congenital heart
disease between October 2014 and October 2015 were
retrospectively analyzed. A written informed consent
was obtained from each parent. The study protocol
was approved by the Baskent University Faculty of
Medicine Ethics Committee (No: KA157305). The
study was conducted in accordance with the principles
of the Declaration of Helsinki.

After retrospective evaluation of the medical
charts and nursing documentations, data including
demographic characteristics of the infants such as age,
gender, and body weight and existing comorbidities
were recorded.

A single anesthetic regimen was used in all patients
(for induction 5 mg/kg sodium thiopental, 0.6 mg/kg
rocuronium, and 2 µg/kg fentanyl). After orotracheal
intubation, the patient was placed in the appropriate
position for the cannulation to visualize the vein
properly, and the area was washed and draped. The
operator was positioned at the head of the bed.

For right IJV cannulation, the patient was positioned
with a rolled towel under the shoulders with the head
turned to the left. First, the right IJV was chosen for
the primary insertion attempt. The right neck was
wrapped using the standard sterile technique. The
jugular venous anatomy was examined through a
7.5 MHz sonographic probe (Sonosite Titan, linear
probe -7.5 MHz) (Figure 1). The compression of the
vein with gentle pressure of a probe on the skin and the
presence of the pulse in the carotid artery (CA) were
confirmed.

The linear probe was connected to a real-time twodimensional
US device (SonoSite, Bothwell, WA, USA)
and focused at 3.5 cm depth. The probe was covered
with ultrasonic gel and wrapped in a sterile cover.

The real-time US is a technique of needle
advancement and vessel puncture under the permanent
US guidance (i.e., the needle is permanently seen on
the US screen). The sonographic probe was placed
perpendicular to the long axis of the vessel, visualizing the vein in the short-axis view as a circle (Figure 2).
Under the sonographic guidance, the right IJV was
punctured (Figure 2).

The success rate, access time, number of attempts,
the incidence of complications during each attempt
(i.e., CA puncture, hematoma, hemodynamic alteration,
pneumothorax, and catheter-related complications such
as kinking or threading difficulties) were recorded.
The access time was defined as the time from the
needle penetration of the skin and to the insertion of
the catheter into the vein over the guidewire with the
removal of the needle entering the skin.

Statistical analysis
Statistical analysis was performed using the
SPSS for Windows version 15.0 software (SPSS
Inc., Chicago, IL, USA). Descriptive data were
expressed in mean ± standard deviation (SD) and
number and frequency (%). Student's t-test was used
for comparison of quantitative variants. Qualitative
variants were compared using chi-square tests or the
Fisher's exact test as appropriate. Pearson correlation
analysis was used to examine the relationships
between the parameters that conform to the normal
distribution. A p value of <0.05 was considered
statistically significant.

Results

Of a total of 70 patients, 20 were younger than
30 days of age and 50 patients were one month to
7.5 month-old. The body weight of the infants were as
follows: four patients (5.7%) less than 2 kg, 10 patients
(14.3%) between 2 to 3 kg, and 56 patients (80%)
between 3 to 5 kg (Table 1).

The success rate of the IJV catheter insertion was
92.8%. Only in five patients (7.14%), the procedure
failed. In these patients, the catheter was inserted
into the femoral vein. In total, 53 CVC (81.5%) were
successful at the first attempt and nine (13.8%) at the
second attempt, while three patients (4.6%) required
?3 punctures.

Complications were observed in five patients
(7.14%) weighing less than 2,500 g. One of them had
a giant teratoma which limited the neck movements
of the patient with a body weight of 950 g. In these
patients, femoral vein catheterization was done rather
than the IJV puncture.

Pneumothorax occurred only in one patient
(1.42%). Hematoma occurred in four patients (5.7%)
due to the multiple IJV cannulation attempts. There
was no CA puncture in any patients (Table 2).

The mean access time was 214±0.48 sec (Table 2).
The weight was correlated with the catheter insertion
time using the Pearson"s correlation coefficient. There
was a statistically significant and negative correlation
between total catheter insertion time and body weight
of the patients (57.7%; p<0.05).

Discussion

In general, CVC is challenging in pediatric patients
due to the small diameter of the vessels. Therefore,
more insertion attempts are often unavoidable, before
successful catheterization can be performed. Usually,
the number of insertion attempts increase the risk of
complications such as CA puncture, pneumothorax,
hemothorax, and subcutaneous extravasation.[3-6]
According to many studies, the success rate is lower
and the complication rate is higher in infants and
children, compared to older children and adults.
Moreover, anomalies and syndromes, prematurity and
short neck can also decrease the procedural success
rate and increase the complication rate.[5-7]

In a retrospective study including 149 patients
undergoing cardiac surgery, Leyvi et al.[8] reported
a success rate of 91.5% in the US group and 72.5%
in the landmark group. In another study including
60 pediatric patients younger than 12 years old who
underwent cardiac surgery, Dalvi et al.[9] found that
the first attempt success was higher in the US group
(73.3%) than the landmark group (36.6%). In the
aforementioned study, the CA puncture was also
higher in the landmark group (43.3%) than the US
group (10%), and the mean number of attempts were
higher in the landmark group than the US group
(p=0.008). Similar findings were also reported by
Verghese et al.[10] In our study, we retrospectively
evaluated the success rate of US-guided CVC in lowweight
pediatric patients undergoing congenital heart
surgery. The overall success rate was 92.8% (n=65), requiring only one attempt in 81.5% of the patients
(n=53). Only 12 patients (18.4%) needed multiple
attempts for successful catheterization, and all of these
patients requiring multiple attempts had lower weight,
compared to the others. The complication rate was
also low (7.1%, n=5). There was no CA puncture in any
patients.

Furthermore, anatomic variations and vascular
anomalies about the IJV and CA in children with
congenital cardiac disease may compromise the
catheterization. According to Troianos et al.,[11] there
was a high incidence (54%) of posteriorly inserted
CA which predisposed the patients to CA puncture, if
the cannulation needle traversed the IJV. According
to Alderson et al.'s study[12] where they examined the
jugular venous anatomy by US in 50 patients younger
than six years of age, there was an anomalous venous
anatomy with an incidence of 18%. In 10% of the
patients, CA was positioned posteriorly. The diameter
of the IJV was also unusually small (?3 mm for
neonates and infants, ≤5 mm for older children) in 4%
of the patients. All of these anomalies increased the
complication rate (20%) in the aforementioned study.

Visualization of the vessels and confirmation of
anatomical variations regarding the IJV-CA relationship
can be obtained by US-guided technique (Figure 1).
The IJV is usually located laterally to the CA. With
the US guidance, this anatomical relationship, arterial
pulsation of the CA and the compression of the IJV
can be seen easily.[13-16] Another important point of the
visualization of the structures is that it is also possible
to see the position of the guidewire and the catheter.[17]

In our clinic, we routinely perform IJV
catheterization as the first choice, if there is no any
contraindication. In this study, similar to previous
studies, we were able to visualize the anatomical
structures and IJV-CA relationship easily under the
guidance of US. We believe that high procedural success rate in our study may be due to the
advantage of using US. Similarly, Verghese et al.[18]
and Grebenik et al.[19] achieved higher success rates
in the US group. In many studies, it was reported
that CVC with the US guidance reduced the access
time and number of puncture attempts for successful
catheterization.[18-21]

On the other hand, according to the study of
Froehlich et al.,[3] there was no significant difference
between the US guidance and landmark technique in
terms of the time spent for catheterization; however,
the authors reported that the time was also dependent
on the experience of the practitioner. In our study,
the mean access time from the first puncture to the
catheter insertion was 214±0.48 sec and catheterization
was performed by two anesthesiologists specialized in
this area.

The age and weight of patients are also critical
factors which affect the success rate and the number
of attempts in catheter insertion. According to our
study, there was a negative correlation between
the weight of the patient and catheter insertion
time and success rate (p<0.05). Froehlich et al.[3]
demonstrated that success rate was lower in children
with low-weight (median weight <16.25 kg) and
multiple attempts were required for both techniques
(US and landmark), compared to high-weight children
(median weight >16.25 kg).

In our study, we found that, with the guidance
of US, CVC could be performed with fewer
complications and a higher success rate in a short
period. Since children with congenital heart disease
are exposed to multiple procedures and frequently
require vascular access for diagnostic, interventional
or medical reasons, CVC with the aid of US seems to
be beneficial. Moreover, we believe that, in addition
to the use of US guidance, optimal positioning,
profound sedation, and the correct choice of the site
and cannulation materials are the other important
factors which affect the success rate.

The limitations of this study include retrospective
design with small sample size and lack of a control
group to compare the usual technique of anatomic
landmarks. Nevertheless, our data can be generalized,
as there are no missing data for any of the patients.

In conclusion, our study results suggest that the
success rate of central catheterization under the
guidance of ultrasound is high and ultrasound-guided
central venous cannulation is a safe and effective
technique, particularly in the pediatric population
weighing less than 5 kg undergoing congenital heart
surgery.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to
the authorship and/or publication of this article.

Funding
The authors received no financial support for the research
and/or authorship of this article.

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